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<br />ti> Minnesota Workers' Compensation Assigned Risk Plan <br />~a C Standard Workers' Compensation and Employers' Liability Policy <br />~ I ' Contract Administrator <br />SerkleyRisl\Adroo.stra\orsCcmpany.lLC Berkley Risk Administrators Company, LLC <br />P.O. Box 59143 Minneapolis, Minnesota 55459-0143 <br />Phone (612) 766-3000 NCCI Carrier Code 21466 <br /> <br />EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT <br /> <br />1. The Insured: <br /> <br />welP <br /> <br />Policy Number: WC-22-o4-159728-03 <br />Association File Number: 3201395 <br /> <br />GNAW INC <br />dba: Centerville Liquor Barrel <br />7093 20th Ave <br />Centerville, MN 55038 <br /> <br />Tax 1D#: F 830385468 <br />UIC #: 068707550000 <br />Policy Period: From: 1f6f2008 <br />To: 116/2009 <br />Endorsement Eft. Date: 1/6/2008 <br />Date of Mailing: 11f2f2007 <br /> <br />The premium for the policy will be adjusted by an experience rating modification factor. The factor was not available <br />when the policy was issued. The factor, if any, shown on the Information Page is an estimate. We will issue an <br />endorsement to show the proper factor, if different from the factor shown, when it is calculated. <br /> <br />All other terms and conditions of this policy remain unchanged. <br /> <br />Aqencv Name and Address <br />Ross Nesbit Agencies Inc <br />Paulet Slater Agency <br />2610 University Ave W <br />St Paul, MN 55114 <br /> <br />WC 00-04-03 <br />3836 639064 <br />